If yes to any of these attach details o yes o no

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Unformatted text preview: or other representative proceeding?
If “Yes” to any of these, attach details. o Yes o No Other than those identified in the response to Section 8(a), are there now
pending or has any claim been brought at any time during the last 5 years
against (i) any Applicant or any entity proposed for coverage or (ii) any
individual proposed for coverage in his or her capacity as a director or officer of
any entity?
If “Yes”, attach details. o Yes o No Pertaining to question 8, it is agreed that any claim arising from such suits, investigation, claim or
proceeding is excluded from the proposed coverage.
9. Current Insurance – MISSOURI APPLICANTS/AGENTS: DO NOT ANSWER QUESTIONS 9 (b)
a. Provide the following information with respect to any executive/directors and officers liability or other
securities liability insurance coverage currently maintained by any Applicant or by any individual or
entity proposed for coverage:
Insurer Limits Retention $ $ $
b. $ $ $ Has any carrier refused or cancelled any executive/directors and officers
liability coverage? 14-03-0715 (Ed. 07/2005) Policy Period 4 of 7 o Yes o No Financial Institution Portfolio SM Chubb Group of Insurance Companies Executive Liability and Entity Securities Liability Coverage
Non-Bank Application 15 Mountain View Road
Warren, New Jersey 07059 c. Provide the following information with respect to any other Bond, Trust Department E&O, and
General Liability coverages currently maintained by any Applicant or by any individual or entity
proposed for coverage.
Coverage Insurer Limits Retention Blanket Bond $ $ Trust Depart E&O $ $ General Liability $ Policy Period $ _ It is represented and agreed that above coverages, referenced in Question 9 (c), in current amounts
will be maintained by the Applicant during the policy period of the proposed insurance and that the
Company is relying upon such representation when issuing a Coverage Section.
10. Is the Applicant currently offering or planning to offer any of the following services?
o
o
o
o
o
o
o
o
o
o
o Actuarial services
Appraisal services
Data processing services
Discount brokerage services
Insurance agent/agency
Investment advisor/counselor
Real estate agent/agency
Real estate investment trust advisory services
Security broker/dealer
Travel agent/agency
Underwriting of securities Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes o
o
o
o
o
o
o
o
o
o
o 11. How often are Board of Directors meetings held? __________________________ 12. List the Board of Directors committees which are in existence and indicate the frequency of meetings:
Committee 13. Indicate the areas in which formal written policies and/or procedures have been implemented by the
Board of Directors to address the following:
Asset-Liability Management Policy
Audit Policy
Conflicts of Interest Policy
Duties of Directors and Officers
Investment Policy
Loan Policy 14. Meeting Frequency Merger or Tender Offers
Operating Procedures
Personnel Policy
Risk Management Policy
Selection Process for New Directors How often does the Board of Directors review the follow...
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